History and Physical
Osteoporosis has no specific clinical signs and symptoms unless there is a fracture. Some patients may complain of bone aches (hips and feet), but the pain is more of a symptom of osteomalacia. Fracture Risk Assessment Tool (FRAX) is available for evaluating 10-year fracture risk probability, especially hip and other major osteoporotic fractures. FRAX assessment takes into consideration of age, family history, smoking status, steroid use, arthritis, and femoral neck bone density. Common manifestations of osteoporosis include vertebral fracture, hip fracture (about 15% of women), and distal radial fractures.[10] Vertebral fractures are typically incidentally noted on imaging as a majority of them are asymptomatic.
Unfortunately, the screening of women for osteoporosis doesn’t have an international following, although, in the United States and Canada, Bone Mineral Density in postmenopausal women greater than 65 years is recommended for screening even without risk factors. There are various risk factors for osteoporosis classified under modifiable and non-modifiable.
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In General, the causes of osteoporosis can be simply classified into Primary and Secondary. Primary is generally age-related influenced by hormonal and dietary elements, while secondary osteoporosis is a result of various medical conditions and medications.
Primary: Primary causes of osteoporosis can be further subclassed into Type 1 and Type 2.
Secondary: Certain Medical conditions increase bone remodeling leading to interference or disruption of bone reformation. There is a resultant bone loss as a consequence of imbalance from new bone production and loss. Some of the common conditions promoting osteoporosis are hyperparathyroidism, hyperthyroidism, diabetes, thalassemia, multiple myeloma, intestinal malabsorption, leukemia, Liver disease, metastatic bone disease, Cushing’s syndrome, acromegaly, scurvy, and Marfan’s syndrome.
In addition to medical conditions, medications that can cause osteoporosis are antacids containing aluminum, heparin, anticonvulsants, thyroxine, and steroid use(cortisone therapy).
Apart from the above-mentioned causes, modifiable risk factors are listed below.
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Non-modifiable risk factors include but are not limited to:
1) History of fracture as an adult or in a first-degree relative
2) White race
3) Advanced age/Dementia/Fragility
4) Female sex
Modifiable risk factors include
1) Current cigarette smoking
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2) Low BMI
3) Early menopause (less than 45-year-old) or bilateral oophorectomy and prolonged premenopausal amenorrhea (for more than a year)
4) Low dietary calcium intake
5) Alcoholism
6) Recurrent falls
7) Inadequate physical activity[11][12]
A thorough history is mandatory to identify known risk factors for osteoporosis and osteoporotic fracture, as listed above. Conditions including COPD (chronic obstructive pulmonary disease), asthma, and other rheumatological disorders like giant cell arteritis, polymyalgia, and others with judicious use of steroids for years predispose patients for secondary osteoporotic risk. Risk factors for falls in older patients include poor balance, weakness of muscles and deconditioning, medications with sedative effects, poor vision, or hearing.[13][14]
Some fractures are picked on incident x-ray findings, especially vertebral. However, there can be associated features of pain, a decrease in height, cord compression features of severe disability in weight-bearing moments from hip fractures. Gait disturbances could also occur as a result of an abnormal pattern of walking and occasional loss of muscle tone and sarcopenia (muscle mass loss)
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